Cardiopulmonary Exercise Testing as a Screening Test for Perioperative Management of Major Surgery in the Elderly

doi:10.1378/chest.116.2.355

Chest

Volume 116, Issue 2, August 1999, Pages 355-362

https://doi.org/10.1378/chest.116.2.355 Get rights and content

Study objective

To develop an integrated strategy for the identification and subsequent management of high-risk patients in order to reduce both morbidity and mortality.

Design

Prospective consecutive series in which all patients underwent cardiopulmonary exercise (CPX) testing.

Setting

CPX laboratory and level 3 ICU and high-dependency unit (HDU) of a metropolitan teaching hospital.

Patients

Five hundred forty-eight patients > 60 years of age (or younger with known cardiopulmonary disease) scheduled for major intra-abdominal surgery.

Interventions

The patients were assigned to one of three management strategies (ICU, HDU, or ward) based on the anaerobic threshold (AT) and ECG evidence of myocardial ischemia as determined by CPX testing that was performed as part of the presurgery evaluation, and by the expected oxygen demand stress of the surgical procedure.

Results

Overall mortality was 3.9%. Forty-three percent of deaths were attributed to poor cardiopulmonary function, as detected preoperatively. There were no deaths related to cardiopulmonary complications in any patient deemed fit for major abdominal surgery and ward management, as determined by CPX testing.

Conclusions

In elderly patients undergoing major intra-abdominal surgery, the AT, as determined by CPX testing, is an excellent predictor of mortality from cardiopulmonary causes in the postoperative period. Preoperative screening using CPX testing allowed the identification of high-risk patients and the appropriate selection of perioperative management.

Section snippets

Patient Selection and CPX

The patients included in this study were those scheduled for major surgery who either were > 60 years of age, or were < 60 years of age but had previous diagnoses of myocardial ischemia or cardiac failure.

CPX testing was used as a screening test on all patients scheduled for major surgery in our hospital. Most of these patients were tested as outpatients up to 2 weeks before the scheduled surgery. This program received the full cooperation of both the anesthesiologists and surgeons, thus

AT and Age Distribution

The age distribution of the patients tested and the distribution of the AT for each age group are displayed in Figure 1 . Eighty-eight percent of patients were ≥ 60 years old, with an average age of 69 years old. Consistent with our previous study,⁵ there were no significant differences in the AT among the age groups. Patients < 60 years old who were tested by CPX had a documented history of myocardial ischemia or cardiac failure.

The overall distribution of AT is shown in Figure 2 . The average

Discussion

Preoperative screening tests for cardiac and pulmonary dysfunction are not routinely performed in most hospitals. CPX testing is an inexpensive and totally noninvasive technique used for the objective evaluation of cardiac and pulmonary function. For this reason, all elderly patients scheduled for major surgery, as well as younger patients with known cardiovascular disease, are routinely screened with CPX at our hospital.

The parameter in which we have the most interest is the AT. This is the

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Cited by (405)

Preoperative aerobic fitness and perioperative outcomes in patients undergoing cystectomy before and after implementation of a national lockdown
2024, BJA Open
Lower fitness is a predictor of adverse outcomes after radical cystectomy. Lockdown measures during the COVID-19 pandemic affected daily physical activity. We hypothesised that lockdown during the pandemic was associated with a reduction in preoperative aerobic fitness and an increase in postoperative complications in patients undergoing radical cystectomy.
We reviewed routine preoperative cardiopulmonary exercise testing (CPET) data collected prior to the pandemic (September 2018 to March 2020) and after lockdown (March 2020 to July 2021) in patients undergoing radical cystectomy. Differences in CPET variables, Postoperative Morbidity Survey (POMS) data, and length of hospital stay were compared.
We identified 267 patients (85 pre-lockdown and 83 during lockdown) who underwent CPET and radical cystectomy. Patients undergoing radical cystectomy throughout lockdown had lower ventilatory anaerobic threshold (9.0 [7.9–10.9] vs 10.3 [9.1–12.3] ml kg⁻¹ min⁻¹; P=0.0002), peak oxygen uptake (15.5 [12.9–19.1] vs 17.5 [14.4–21.0] ml kg⁻¹ min⁻¹; P=0.015), and higher ventilatory equivalents for carbon dioxide (34.7 [31.4–38.5] vs 33.4 [30.5–36.5]; P=0.030) compared with pre-lockdown. Changes were more pronounced in males and those aged >65 yr. Patients undergoing radical cystectomy throughout lockdown had a higher proportion of day 5 POMS-defined morbidity (89% vs 75%, odds ratio [OR] 2.698, 95% confidence interval [CI] 1.143–6.653; P=0.019), specifically related to pulmonary complications (30% vs 13%, OR 2.900, 95% CI 1.368–6.194; P=0.007) and pain (27% vs 9%, OR 3.471, 95% CI 1.427–7.960; P=0.004), compared with pre-lockdown on univariate analysis.
Lockdown measures in response to the COVID-19 pandemic were associated with a reduction in fitness and an increase in postoperative morbidity among patients undergoing radical cystectomy.
Association between preoperative physical exercise and quality of life in cardiac surgery
2023, Cirugia Cardiovascular
La relación entre el ejercicio físico previo a la intervención y la calidad de vida, el riesgo de complicaciones o muerte no ha sido estudiado.
Estudio de cohortes prospectivo. Se analizó la mejoría en la calidad de vida entre antes de la operación y a 6 meses mediante las escalas EUROQOL y EVA. El nivel de ejercicio físico se analizó mediante MET. Se evaluó la mejoría en la calidad de vida en función del nivel de ejercicio previo, se estudió si a mayor nivel de ejercicio, mayor aumento en la calidad de vida y se analizó la relación entre el ejercicio y las complicaciones postoperatorias o muerte.
La cirugía cardiaca mejora la calidad de vida según ambas escalas; EVA 17,8 ± 18,8 puntos (p < 0,001) y EUROQOL 1,1 ± 1,1 puntos (p < 0,001). El mayor nivel de ejercicio previo no llevó a una mayor mejoría en la calidad de vida, pero sí se asoció a menor riesgo de shock cardiogénico (p = 0,032), postoperatorio complicado (p = 0,034) y el evento combinado postoperatorio combinado o muerte (p = 0,027).
La cirugía cardiaca mejora la calidad de vida a los 6 meses El mayor nivel de ejercicio no se asocia a una mayor mejoría en la calidad de vida. Un mayor nivel de ejercicio físico está asociado a un menor riesgo de postoperatorio complicado o muerte.
The relationship between pre-intervention physical exercise and quality of life, risk of complications or death has not been studied.
Prospective cohort study. Improvement in quality of life between preoperatively and at 6 months was analyzed using the EUROQOL scale and VAS. The level of physical exercise was analyzed by METS. The improvement in quality of life was evaluated according to the previous level of exercise and we studied whether the higher the level of exercise, the greater the increase in quality of life.
Quality of life improved according both scales; VAS 17.8 ± 18.8 points (p < 0.001) and EUROQOL 1.1 ± 1.1 points (p < 0.001). Patients improved their quality of life. The higher level of previous exercise did not lead to a greater improvement in quality of life, but it did reduce the event of cardiogenic shock (p = 0.032), complicated postoperative (p = 0.034) and the combined event combined postoperative or death (p = 0.027).
Cardiac surgery improves quality of life at six months for all patients. A higher level of exercise is not related with a greater improvement in quality of life. A higher level of physical exercise is associated with less risk of postoperative complications or death.
Sex-related differences in functional capacity and its implications in risk stratification before major non-cardiac surgery: a post hoc analysis of the international METS study
2023, eClinicalMedicine
Poor functional capacity has been identified as an important modifiable risk factor for postoperative complications. Cardiopulmonary exercise testing (CPET) provides objective parameters of functional capacity (e.g., oxygen consumption at peak exercise, peak VO₂), with significant prognostication for postoperative complications. However, sex-specific thresholds for functional capacity to predict surgical risk are yet to be established. Therefore, we performed a post hoc analysis of the international, multicentre, prospective observational METS (Measurement of Exercise Tolerance before Surgery) study to evaluate if sex-specific thresholds of peak VO₂ improve risk prediction of postoperative complications.
We undertook a post hoc analysis (HREC/71824/PMCC) of the METS study, which was performed between March 2013 and March 2016. We investigated whether sex-specific differences exist for CPET-derived parameters and associated thresholds for predicting postoperative complications in this large cohort of patients that had major non-cardiac surgery (n = 1266). Logistic regression models were analyzed for the association of low peak VO₂ with moderate-to-severe in-hospital postoperative complications. Optimal sex-specific peak VO₂ thresholds were obtained by maximizing the Youden index of receiver operating characteristic (ROC) curves. Finally, multivariable logistic regression models tested the resulting sex-specific thresholds against the established non-sex-specific peak VO₂ threshold (14 mL kg⁻¹ min⁻¹) adjusted for clinically relevant features such as comorbidities and surgical complexity. Models were evaluated by bootstrapping optimism-corrected area under the ROC curve and the net reclassification improvement index (NRI).
Female patients (n = 480) had a lower mean (SD) peak VO₂ than males (16.7 (4.9) mL kg⁻¹ min⁻¹ versus 21.2 (6.5) mL kg⁻¹ min⁻¹, p < 0.001) and a lower postoperative complication rate (10.4% versus 15.3%; p = 0.018) than males (n = 786). The optimal peak VO₂ threshold for predicting postoperative complications was 12.4 mL kg⁻¹ min⁻¹ for females and 22.3 mL kg⁻¹ min⁻¹ for males, respectively. In the multivariable regression model, low non-sex-specific peak VO₂ did not independently predict postoperative complications. In contrast, low sex-specific peak VO₂ was an independent predictor of postoperative complications (OR 2.29; 95% CI: 1.60, 3.30; p < 0.001). The optimism-corrected AUC-ROC of the sex-specific model was higher compared with the non-sex-specific model (0.73 versus 0.7; DeLong’s test: p = 0.021). The sex-specific model classified 39% of the patients more correctly than the baseline model (NRI = 0.39; 95% CI: 0.24, 0.55). In contrast, the non-sex-specific model only classified 9% of the patients more correctly when compared against the baseline model (NRI = 0.09; 95% CI: −0.04, 0.22).
Our data report sex-specific differences in preoperative CPET-derived functional capacity parameters. Sex-specific peak VO₂ thresholds identify patients at increased risk for postoperative complications with a higher discriminatory ability than a sex-unspecific threshold. As such, sex-specific threshold values should be considered in preoperative CPET to potentially improve risk stratification and to guide surgical decision-making, including eligibility for surgery, preoperative optimization strategies (prehabilitation) or seeking non-surgical options.
There was no funding for the present study. The original METS study was funded by Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.
Postoperative hyperlactataemia and preoperative cardiopulmonary exercise testing in an elective noncardiac surgical cohort: a retrospective observational study
2023, BJA Open
Blood lactate concentration in the postoperative period is a marker of physiological stress and a predictor of complications and mortality. Cardiopulmonary exercise testing (CPET) is a common preoperative risk stratification tool. We aimed to investigate the association between preoperative CPET results and postoperative lactate concentration with postoperative mortality after major noncardiac surgery.
We analysed data from patients undergoing major noncardiac surgery in a tertiary UK centre between 2007 and 2014 who had preoperative CPET and postoperative lactate measurements. Univariate and multivariate analyses were performed to assess the association between lactate concentration, CPET results, or both and mortality.
We analysed data from 1075 patients. A mean lactate concentration >2 mM in the first 12, 24, and 48 h after surgery was associated with odds ratios (ORs) and 95% confidence intervals (CIs) for 30-day mortality of 3.9 (2.1–7.3; P<0.005), 4.5 (2.4–8.4; P<0.005), and 6.1 (3.3–11.5; P<0.005), respectively. The dichotomous CPET variable, ventilatory equivalence for CO₂ (V̇E/V̇_co2; cut-off 34), was associated with increased risk of 30-day mortality (OR 2.5; 95% CI: 1.3–4.8; P<0.005). In a multivariable model, hyperlactataemia and poor V̇E/V̇_co2 retained their significant associations with 30- and 90-day mortality when adjusted for age, BMI, and surgical risk. When looking at the combined effect of the dichotomous hyperlactataemia in the first 24 h (cut-off 2 mM) and preoperative V̇E/V̇_co2, the OR for 30-day mortality was 11.53 (95% CI: 4.6–28.8; P≤0.005).
Our study suggests that postoperative hyperlactataemia and preoperative poor V̇E/V̇_co2 are independently associated with an increased risk of mortality after major noncardiac surgery.
Physiological relationship between cardiorespiratory fitness and fitness for surgery: a narrative review
2023, British Journal of Anaesthesia
Epidemiological evidence has highlighted a strong relationship between cardiorespiratory fitness and surgical outcomes; specifically, fitter patients possess heightened resilience to withstand the surgical stress response. This narrative review draws on exercise and surgical physiology research to discuss and hypothesise the potential mechanisms by which higher fitness affords perioperative benefit. A higher fitness, as indicated by higher peak rate of oxygen consumption and ability to sustain metabolic homeostasis (i.e. higher anaerobic threshold) is beneficial postoperatively when metabolic demands are increased. However, the associated adaptations with higher fitness, and the related participation in regular exercise or physical activity, might also underpin the observed perioperative benefit through a process of hormesis, a protective adaptive response to the moderate and intermittent stress of exercise. Potential mediators discussed include greater antioxidant capacity, metabolic flexibility, glycaemic control, lean body mass, and improved mood.
Pick Your Threshold: A Comparison Among Different Methods of Anaerobic Threshold Evaluation in Heart Failure Prognostic Assessment
2022, Chest
In clinical practice, anaerobic threshold (AT) is used to guide training and rehabilitation programs, to define risk of major thoracic or abdominal surgery, and to assess prognosis in heart failure (HF). AT of oxygen uptake ( $\dot{V}$ O₂; $\dot{V}$ O₂AT) has been reported as an absolute value ( $\dot{V}$ O₂ATabs), as a percentage of predicted peak $\dot{V}$ O₂ ( $\dot{V}$ O₂AT%peak_pred), or as a percentage of observed peak $\dot{V}$ O₂ ( $\dot{V}$ O₂AT%peak_obs). A direct comparison of the prognostic power among these different ways to report AT is missing.
What is the prognostic power of these different ways to report AT?
In this observational cohort study, we screened data of 7,746 patients with HF with a history of reduced ejection fraction (< 40%) recruited between 1998 and 2020 and enrolled in the Metabolic Exercise Combined With Cardiac and Kidney Indexes register. All patients underwent a maximum cardiopulmonary exercise test, executed using a ramp protocol on an electronically braked cycle ergometer.
This study considered 6,157 patients with HF with identified AT. Follow-up was median, 4.2 years (25th-75th percentiles, 1.9-5.0 years). Both $\dot{V}$ O₂ATabs (mean ± SD, 823 ± 305 mL/min) and $\dot{V}$ O₂AT%peak_pred (mean ± SD, 39.6 ± 13.9%), but not $\dot{V}$ O₂AT%peak_obs (mean ± SD, 69.2 ± 17.7%), well stratified the population regarding prognosis (composite end point: cardiovascular death, urgent heart transplant, or left ventricular assist device). Comparing area under the receiver operating characteristic curve (AUC) values, $\dot{V}$ O₂ATabs (0.680) and $\dot{V}$ O₂AT%peak_pred (0.688) performed similarly, whereas $\dot{V}$ O₂AT%peak_obs (0.538) was significantly weaker (P < .001). Moreover, the $\dot{V}$ O₂AT%peak_pred AUC value was the only one performing as well as the AUC based on peak $\dot{V}$ O₂ (0.710), with an even a higher AUC (0.637 vs 0.618, respectively) in the group with severe HF (peak $\dot{V}$ O₂ < 12 mL/min/kg). Finally, the combination of $\dot{V}$ O₂AT%peak_pred with peak $\dot{V}$ O₂ and $\dot{V}$ per CO₂ production shows the highest prognostic power.
In HF, $\dot{V}$ O₂AT%peak_pred is the best way to report $\dot{V}$ O₂ at AT in relationship to prognosis, with a prognostic power comparable to that of peak $\dot{V}$ O₂ and, remarkably, in patients with severe HF.

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^†: Deceased.

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Chest

Clinical InvestigationsExerciseCardiopulmonary Exercise Testing as a Screening Test for Perioperative Management of Major Surgery in the Elderly

Study objective

Design

Setting

Patients

Interventions

Results

Conclusions

Section snippets

Patient Selection and CPX

AT and Age Distribution

Discussion

Chest

New classification of physical status

Anesthesiology

Multifactorial index of cardiac risk in noncardiac surgical procedures

N Engl J Med

The report of a confidential enquiry into perioperative deaths

Deaths associated with anesthesia and surgery in Finland in 1986 compared to 1995

Acta Anaesthesiol Scand

Preoperative evaluation of cardiac failure and ischemia in elderly patients by cardiopulmonary exercise testing

Chest

The role of cardiopulmonary exercise testing for preoperative evaluation of the elderly

Clinical Investigations
Exercise
Cardiopulmonary Exercise Testing as a Screening Test for Perioperative Management of Major Surgery in the Elderly